243
Royal Society of Health Journal
DECEMBER 1978
VOLUME98N06
PROBLEM DRINKERS
problems are
KESSEL Committee describe their report on Pattern and Range of Services for Problem Drinkers’ as &dquo;a modest and gradual approach&dquo;. This is the second report to have been produced by the Department of Health and Social Security Advisory Committee on Alcoholism and, as its predecessor did on the subject of prevention, the present document presents a thorough and workman-like review of the services available for problem drinkers. At the same time, however, its recommendations for future development are hardly likely to raise an outcry; indeed, it would be surprising if they raised so much as
HE
, ‘The
an
eyebrow.
The report has two principal themes: co-ordination of services and the early identification of problem drinkers. It recognizes that the present pattern of services is patchy and irregular, comprising, as it does in most areas, an ill-organized hotch-potch of statutory and voluntary bodies with disparate and, from time to time, incompatible aims. That this range of services requires to be co-ordinated is indeed a truism that few people involved in the alcoholism field would gainsay. The issue which has to be addressed is, therefore, how this miracle of co-ordination is to be achieved. They make a promising start, the Kessel Committee, by dividing treatment agencies into primary and secondary levels. Primary level workers are those whose responsibilities are of a general and non-specialized nature, they include members of the primary health care team, personal social services and voluntary workers from a wide range of bodies. Secondary level workers are those with special responsibilities for dealing with problem drinkers and, one would hope, special training in the knowledge and skills actually required, although this is perhaps less often the case than the Kessel Committee suggest. In any case, secondary level workers are either professional staff, such as psychiatrists and specialist social workers, or voluntary workers such as counsellors at local councils on alcoholism. This split of workers into primary and secondary, whilst hardly of startling originality in health services generally, is indeed a more rational approach to alcoholism services than those involved in the delivery of the services have been prepared to opt of their own volition. Similarly, the emphasis which the Kessel Committee place upon the crucial role of the primary level workers to identify and to provide substantial help for problem drinkers is a welcome recognition of the inevitability of more comprehensive service provision, if indeed alcoholism treatment is ever to do more than paper over the cracks. It is here too that the second major theme, that of early identification, is most persuasively argued. There can be no doubt that drinking
far
more
likely to be
resolved where
they
are recognized early and countered with effective treatment. Clearly, it will usually be the generalist (and
inevitably one is thinking here particularly of the primary health care team) rather than the remote ethanologist who is more likely to be the first point of contact for somebody whose drinking is beginning to cause them problems. Perhaps it is not the function of reports of advisory committees to excite their readers. One might have wished, however, for something to set the heart racing just a little over the central problem of how these neatly rationalized services are actually to be co-ordinated in practice. We are assured that this will vary according to local circumstances. It would have been encouraging to gain the impression that these variations would cluster firm model which the Kessel Committee least, backed to win. Instead, their approach is so modest and so gradual that it is always going to be difficult to know which development they have stimulated and which they have merely reflected. around
had,
some
at the very
DOCTOR MANPOWER 1975-2000
by the Royal Commission UBLISHED Health Service with the
the of JL ’stimulating and informing public discussion’ Doctor Manpower 1975-2000 - alternative forecasts and their resource implications examines in its first section the structure of the available medical manpower: the intake of medical schools, the choice of a career, the increasing proportion of women doctors, and immigration and emigration. In this section the authors, Alan Maynard and Arthur Walker, two economists of the University of York, are on firm factual ground, and if their jargon is penetrated, have provided a useful collection of information. The second and third sections are concerned with forecasting first the desirable and then the possible developments. The authors state that: ’The market for doctors is dynamic and responsive to policy changes. Consequently the interactions between supply and
National
Downloaded from rsh.sagepub.com at UNIVERSITY OF SASKATCHEWAN LIBRARY on August 13, 2015
on
object
244 demand must be recognized as agents increasing the uncertainty of outcomes and necessitating careful modelling, a good data base and extensive sensitivity analyses’. Certain assumptions are described and then forecasts made: ’the best guess’, and then high esti-
mates and low estimates are given. The best guess is that from 1975 to 2000 the total number of doctors will increase by 38.79 per cent from 64,674 to 89,765. These estimates include an increase of 193.92 per cent in British and Irish women graduates and a fall of 28.69 per cent in foreign men. Finally Regional variations in medical manpower are discussed as the distribution of doctors between the’different specialties is examined. The authors believe that ’by starting with a statement of policy objectives which are costed so that the budget constraint is not violated, calculating service implications and deriving the capital and labour which is needed to provide their services, forecasts of the manpower requirements for all grades of staff ... could be derived’. This paper is the work of two academics whose knowledge of economics is unquestioned, but whose understanding of the National Health Service is certainly not great. Consider just two of their statements and conclusions &dquo;A major resource implication of an increased stock of general practitioners is that the drug bill may increase. We have taken the average cost of drugs per patient on the list in England in 1976, multiplied it by 2300 (the average list size in England) to arrive at an estimate of the average drug expenditure. This figure we have applied to the Great Britain doctor stock forecasts for the years 1980, 1990 and 2000.&dquo; Surely the cost of drugs should be related not to the number of doctors but to the number of patients whom they are treating. After recording that the quality of intake, as measured by ’A’ level grades is higher (for medical schools) than that in most University subjects, and making an assumption of a failure rate of 9 per cent the authors state: ’Ostensibly in an effort to improve the quality of the doctors, the Temporary Registration Assessment Board has been established to ensure that doctors are suitably qualified. In 1976 only 36 per cent (506 out of 1420) of doctors passed the T.R.A.B.... The T.R.A.B. texts, if they are really concerned with protecting the public interest by ensuring competence in doctors, should be applied to all doctors not just new immigrants. Many of those already registered might well fail the T.R.A.B. tests. It is unfortunate that the logic of the competence argument is not taken to its full conclusion. It is also unfortunate that the authors do not realize that it was not the competence and the linguistic ability of the products of United Kingdom Medical Schools which was causing such real and justifiable anxiety in 1975. -
FUTURE OF MENTAL HOSPITALS R WELL OVER a century, the care of the
mentally
ill in most developed countries has -~- centred on large mental hospitals. Though they originally had the positive merits of protecting those patients who could not care for themselves in the outside world and of protecting the public from serious deviant behaviour, these merits became overshadowed in time by the obvious drawbacks of the asylum. These drawbacks included excessive size, poor standards of
staffing and accommodation, geographical isolation and a peculiar internal culture (institutionalism) related to isolation from the general community. Over the course
of time, the effect of these factors was to result in accumulation of steadily growing numbers of long-stay patients, mostly suffering from schizophrenia or senile disorders. From time to time, the World Health Organization has considered the role of the mental hospital in relation to the general provision of mental health services. A new report (The Future o f Mental Hospitals) has now been published by the European Office of W.H.O. and results from a Working Group which met in 1976. Readers in the United Kingdom will note that in 1972, 74 per cent of psychiatric admissions were still going into mental hospitals, but that the overall psychiatric admission rate had begun to fall in 1973. The total of ’old’ long-stay patients, i.e. those who had been in hospital for over five years, has been declining in England and Wales at about 71 per cent per annum, but they still occupy half of all psychiatric beds. ’New’ long-stay patients, who have been in hospital for between one and five years, occupy 20 per cent of beds, but the trend of their numbers is still uncertain. National economic difficulties make it unlikely that any mental hospitals can be completely replaced by other facilities in the foreseeable future. This W.H.O. report makes a number of recommendations which will be no surprise to those working in mental health services. For instance, no new isolated units should be established; all general hospitals should have a psychiatric department, mentally retarded patients should be dealt with by separate services unless they are mentally ill; all potential patients should be carefully screened before admission and there should be free movement of patients between the various parts of the psychiatric service. This is conventional wisdom and as far as the U.K. is concerned, the problems are more of providing resources than of establishing principles. However, compared with most other countries the U.K. is fortunate in being relatively free of administrative barriers and having little complication from the existence of private practice. We could, in fact, provide model services if sufficient determination and financial support were put into the endeavour.
SMOKING — A NEW ELEMENT on health as a result of revealed at a World Health Organ-~- ization (WHO) Expert Committee on Smoking Control, which concluded its work in Geneva on 28 October. One new element in the tobacco controversy is that when control measures were introduced in industrialized countries it was hoped that the tobacco companies would manufacture other products. Instead of that there appears to be an effort to conquer new markets both among women and in the developing countries. In the Third World, where there are few if any controls, such campaigns can go on unabated. So far there is little counter-information about the dangers of cigarette smoking in developing countries and smokers do not know that they are getting cigarettes with twice the tar content allowed in the industrialized countries. The WHO Expert Committee felt there was much room and a unique opportunity for health protection and promotion in this field.
EW ADVERSE effects
smocking
were
Downloaded from rsh.sagepub.com at UNIVERSITY OF SASKATCHEWAN LIBRARY on August 13, 2015
Royal Society of Health Journal
DECEMBER 1978
VOLUME98N06
PROBLEM DRINKERS
problems are
KESSEL Committee describe their report on Pattern and Range of Services for Problem Drinkers’ as &dquo;a modest and gradual approach&dquo;. This is the second report to have been produced by the Department of Health and Social Security Advisory Committee on Alcoholism and, as its predecessor did on the subject of prevention, the present document presents a thorough and workman-like review of the services available for problem drinkers. At the same time, however, its recommendations for future development are hardly likely to raise an outcry; indeed, it would be surprising if they raised so much as
HE
, ‘The
an
eyebrow.
The report has two principal themes: co-ordination of services and the early identification of problem drinkers. It recognizes that the present pattern of services is patchy and irregular, comprising, as it does in most areas, an ill-organized hotch-potch of statutory and voluntary bodies with disparate and, from time to time, incompatible aims. That this range of services requires to be co-ordinated is indeed a truism that few people involved in the alcoholism field would gainsay. The issue which has to be addressed is, therefore, how this miracle of co-ordination is to be achieved. They make a promising start, the Kessel Committee, by dividing treatment agencies into primary and secondary levels. Primary level workers are those whose responsibilities are of a general and non-specialized nature, they include members of the primary health care team, personal social services and voluntary workers from a wide range of bodies. Secondary level workers are those with special responsibilities for dealing with problem drinkers and, one would hope, special training in the knowledge and skills actually required, although this is perhaps less often the case than the Kessel Committee suggest. In any case, secondary level workers are either professional staff, such as psychiatrists and specialist social workers, or voluntary workers such as counsellors at local councils on alcoholism. This split of workers into primary and secondary, whilst hardly of startling originality in health services generally, is indeed a more rational approach to alcoholism services than those involved in the delivery of the services have been prepared to opt of their own volition. Similarly, the emphasis which the Kessel Committee place upon the crucial role of the primary level workers to identify and to provide substantial help for problem drinkers is a welcome recognition of the inevitability of more comprehensive service provision, if indeed alcoholism treatment is ever to do more than paper over the cracks. It is here too that the second major theme, that of early identification, is most persuasively argued. There can be no doubt that drinking
far
more
likely to be
resolved where
they
are recognized early and countered with effective treatment. Clearly, it will usually be the generalist (and
inevitably one is thinking here particularly of the primary health care team) rather than the remote ethanologist who is more likely to be the first point of contact for somebody whose drinking is beginning to cause them problems. Perhaps it is not the function of reports of advisory committees to excite their readers. One might have wished, however, for something to set the heart racing just a little over the central problem of how these neatly rationalized services are actually to be co-ordinated in practice. We are assured that this will vary according to local circumstances. It would have been encouraging to gain the impression that these variations would cluster firm model which the Kessel Committee least, backed to win. Instead, their approach is so modest and so gradual that it is always going to be difficult to know which development they have stimulated and which they have merely reflected. around
had,
some
at the very
DOCTOR MANPOWER 1975-2000
by the Royal Commission UBLISHED Health Service with the
the of JL ’stimulating and informing public discussion’ Doctor Manpower 1975-2000 - alternative forecasts and their resource implications examines in its first section the structure of the available medical manpower: the intake of medical schools, the choice of a career, the increasing proportion of women doctors, and immigration and emigration. In this section the authors, Alan Maynard and Arthur Walker, two economists of the University of York, are on firm factual ground, and if their jargon is penetrated, have provided a useful collection of information. The second and third sections are concerned with forecasting first the desirable and then the possible developments. The authors state that: ’The market for doctors is dynamic and responsive to policy changes. Consequently the interactions between supply and
National
Downloaded from rsh.sagepub.com at UNIVERSITY OF SASKATCHEWAN LIBRARY on August 13, 2015
on
object
244 demand must be recognized as agents increasing the uncertainty of outcomes and necessitating careful modelling, a good data base and extensive sensitivity analyses’. Certain assumptions are described and then forecasts made: ’the best guess’, and then high esti-
mates and low estimates are given. The best guess is that from 1975 to 2000 the total number of doctors will increase by 38.79 per cent from 64,674 to 89,765. These estimates include an increase of 193.92 per cent in British and Irish women graduates and a fall of 28.69 per cent in foreign men. Finally Regional variations in medical manpower are discussed as the distribution of doctors between the’different specialties is examined. The authors believe that ’by starting with a statement of policy objectives which are costed so that the budget constraint is not violated, calculating service implications and deriving the capital and labour which is needed to provide their services, forecasts of the manpower requirements for all grades of staff ... could be derived’. This paper is the work of two academics whose knowledge of economics is unquestioned, but whose understanding of the National Health Service is certainly not great. Consider just two of their statements and conclusions &dquo;A major resource implication of an increased stock of general practitioners is that the drug bill may increase. We have taken the average cost of drugs per patient on the list in England in 1976, multiplied it by 2300 (the average list size in England) to arrive at an estimate of the average drug expenditure. This figure we have applied to the Great Britain doctor stock forecasts for the years 1980, 1990 and 2000.&dquo; Surely the cost of drugs should be related not to the number of doctors but to the number of patients whom they are treating. After recording that the quality of intake, as measured by ’A’ level grades is higher (for medical schools) than that in most University subjects, and making an assumption of a failure rate of 9 per cent the authors state: ’Ostensibly in an effort to improve the quality of the doctors, the Temporary Registration Assessment Board has been established to ensure that doctors are suitably qualified. In 1976 only 36 per cent (506 out of 1420) of doctors passed the T.R.A.B.... The T.R.A.B. texts, if they are really concerned with protecting the public interest by ensuring competence in doctors, should be applied to all doctors not just new immigrants. Many of those already registered might well fail the T.R.A.B. tests. It is unfortunate that the logic of the competence argument is not taken to its full conclusion. It is also unfortunate that the authors do not realize that it was not the competence and the linguistic ability of the products of United Kingdom Medical Schools which was causing such real and justifiable anxiety in 1975. -
FUTURE OF MENTAL HOSPITALS R WELL OVER a century, the care of the
mentally
ill in most developed countries has -~- centred on large mental hospitals. Though they originally had the positive merits of protecting those patients who could not care for themselves in the outside world and of protecting the public from serious deviant behaviour, these merits became overshadowed in time by the obvious drawbacks of the asylum. These drawbacks included excessive size, poor standards of
staffing and accommodation, geographical isolation and a peculiar internal culture (institutionalism) related to isolation from the general community. Over the course
of time, the effect of these factors was to result in accumulation of steadily growing numbers of long-stay patients, mostly suffering from schizophrenia or senile disorders. From time to time, the World Health Organization has considered the role of the mental hospital in relation to the general provision of mental health services. A new report (The Future o f Mental Hospitals) has now been published by the European Office of W.H.O. and results from a Working Group which met in 1976. Readers in the United Kingdom will note that in 1972, 74 per cent of psychiatric admissions were still going into mental hospitals, but that the overall psychiatric admission rate had begun to fall in 1973. The total of ’old’ long-stay patients, i.e. those who had been in hospital for over five years, has been declining in England and Wales at about 71 per cent per annum, but they still occupy half of all psychiatric beds. ’New’ long-stay patients, who have been in hospital for between one and five years, occupy 20 per cent of beds, but the trend of their numbers is still uncertain. National economic difficulties make it unlikely that any mental hospitals can be completely replaced by other facilities in the foreseeable future. This W.H.O. report makes a number of recommendations which will be no surprise to those working in mental health services. For instance, no new isolated units should be established; all general hospitals should have a psychiatric department, mentally retarded patients should be dealt with by separate services unless they are mentally ill; all potential patients should be carefully screened before admission and there should be free movement of patients between the various parts of the psychiatric service. This is conventional wisdom and as far as the U.K. is concerned, the problems are more of providing resources than of establishing principles. However, compared with most other countries the U.K. is fortunate in being relatively free of administrative barriers and having little complication from the existence of private practice. We could, in fact, provide model services if sufficient determination and financial support were put into the endeavour.
SMOKING — A NEW ELEMENT on health as a result of revealed at a World Health Organ-~- ization (WHO) Expert Committee on Smoking Control, which concluded its work in Geneva on 28 October. One new element in the tobacco controversy is that when control measures were introduced in industrialized countries it was hoped that the tobacco companies would manufacture other products. Instead of that there appears to be an effort to conquer new markets both among women and in the developing countries. In the Third World, where there are few if any controls, such campaigns can go on unabated. So far there is little counter-information about the dangers of cigarette smoking in developing countries and smokers do not know that they are getting cigarettes with twice the tar content allowed in the industrialized countries. The WHO Expert Committee felt there was much room and a unique opportunity for health protection and promotion in this field.
EW ADVERSE effects
smocking
were
Downloaded from rsh.sagepub.com at UNIVERSITY OF SASKATCHEWAN LIBRARY on August 13, 2015
